Comparative short-term outcomes of double-kissing culotte and culotte techniques in acute coronary syndrome: A Multicenter Retrospective Study

Comparative short-term outcomes of double-kissing culotte and culotte techniques in acute coronary syndrome: A Multicenter Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Comparative short-term outcomes of double-kissing culotte and culotte techniques in acute coronary syndrome: A Multicenter Retrospective Study Mateusz Barycki, Adrian Włodarczak, Piotr Rola, Szymon Włodarczak, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4338717/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Dec, 2024 Read the published version in Journal of Clinical Medicine → Version 1 posted You are reading this latest preprint version Abstract The double-kissing (DK) culotte technique, a modification of the traditional culotte stenting with additional kissing balloon inflation after first stent implantation, was compared to the conventional culotte technique in a multicenter, observational, retrospective study of 239 patients with acute coronary syndrome. Patients were treated at two high-volume centers, with 117 patients undergoing the DK culotte and 122 patients undergoing the traditional culotte technique. The primary endpoint, target lesion failure (TLF), occurred in 6.84% of the DK culotte group and 13.11% of the culotte group after a one-year period (p = 0.085). Major adverse cardiac events (MACE) were also lower in the DK culotte group (12.82% vs. 19.67%; p = 0.073), but the differences were not statistically significant. No significant differences were found in contrast medium use (220 mL vs. 230 mL; p = 0.214) or cumulative radiation dose (1868 mGy vs. 2114.5 mGy; p = 0.127). The results indicate a trend towards better clinical outcomes with the DK culotte technique without increased procedural risks. However, these findings need further validation in prospective studies. ClinicalTrials.gov: NCT06284057 Health sciences/Cardiology/Interventional cardiology Health sciences/Medical research/Outcomes research acute coronary syndrome percutaneous coronary intervention endovascular procedures Figures Figure 1 1. INTRODUCTION Bifurcation lesions remain a complex challenge for interventional cardiologists despite significant advances in the devices and techniques used in percutaneous coronary intervention (PCI). These lesions are relatively prevalent, accounting for 15–20% of all PCI cases [1] . The provisional stenting technique has recently shown more consistent results, but due to the diversity and complexity of the anatomical subset in bifurcation lesions, a single stent strategy may cause the loss of functionally significant side branches, affecting short and long-term outcomes [2, 3] . This challenging scenario is frequently related to so-called “true” bifurcations, where both the main branch (MB) and side branch (SB) are significantly narrowed (> 50% diameter stenosis) and “non-true” bifurcations, which include all the other lesions involving a bifurcation [4] . Two-stent techniques have been introduced into clinical practice to address these anatomical obstacles. However, these techniques distort the stent structure in the bifurcation area and, depending on the technique used may result in the placement of two or even three layers of metal struts against the vessel wall. This could significantly affect postoperative outcomes, particularly in a highly thrombotic subset of acute coronary syndromes (ACS). The optimal technique for two-stent PCI is currently a topic of ongoing debate, with increasing data available on this subject [5, 6] . The culotte technique, introduced by Chevalier [7] , is a well-established two-stent procedure that has demonstrated a favorable safety profile and positive clinical outcomes [8, 9] . Despite its firmly established role in the PCI armamentarium, recent bench test data [10] indicate that a modification to this technique, known as the Double Kissing (DK) culotte could facilitate the procedure's performance and potentially improve clinical outcomes. The DK-culotte technique is a variation of the classical culotte technique characterized by an additional kissing balloon (KB) inflation that follows SB stenting (inverted technique) or MB stenting (conventional technique) and precedes the second branch stent implantation. This additional step reduces the risk of the first implanted stent's struts being pulled towards the ostium when deploying the second stent. During the culotte technique, pulling the struts may result in incomplete coverage of the ostium after the final KB if the rewiring was performed incorrectly. There is a lack of data regarding the outcomes of the DK culotte technique, with only a few case reports available [11, 12] . Based on these preliminary insights and the need for further clinical validation, it is hypothesized that the DK-Culotte technique may offer better clinical outcomes than the standard Culotte technique. 2. Materials and methods 2.1 Study population The Lower Silesia culotte Bifurcation Registry (LSCBR) is a multicenter retrospective analysis aimed at assessing the short-term outcomes of bifurcation PCI in patients with ACS using two different techniques, DK culotte and culotte. This study retrospectively analyzed subjects who underwent PCI in two high-volume cooperative Cardiac Departments in the Lower Silesia Region (Poland) from September 2013 to December 2022, during ACS. During these periods, all PCI data were screened for bifurcation lesions that were responsible for ACS and required subsequent two-stent implantation. A total of 117 patients were assigned to the DK-culotte group, and 122 patients were assigned to the control culotte group (see Central Illustration). Patients who qualified for the two-stent technique a priori and those who required a second stent as a bail-out strategy after the provisional approach were eligible for the registry. The decision to perform PCI was based on clinical indications, such as ongoing ischemia, significant angiographic coronary artery disease (CAD) that is suitable for PCI under the European Society of Cardiology recommendations, patient preference against alternative treatment options, or the decision of the Heart Team. The decision to perform PCI with the selected two-stent technique with second- and third-generation drug-eluting stents (DES) was left to the interventional cardiologist’s discretion based on clinical and angiographic features. The analysis excluded patients who had undergone PCI with coronary stenting of the bifurcation lesion under investigation before the index procedure or suffered prehospital cardiac arrest. No vessel-related exclusion criteria were applied. The Bioethics Committee of the Lower Silesian Medical Association (Poland) approved this study (01/BO/2023). All patients were fully informed of all treatment options and risks associated with PCI before signing written consent for the procedure. Informed consent was obtained from all individual participants included in the study for both participation and the publication of identifying information/images. This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. This study was registered in the ClinicalTrials.gov database under registration number NCT06284057. 2.2 Study endpoints The study’s primary endpoint was target lesion failure (TLF), which is a composite of cardiovascular (CV) death, target vessel myocardial infarction (TV-MI), or clinically driven target lesion revascularization (TLR) at the 1-year follow-up [13] . Additionally, the study evaluated the prevalence of secondary endpoints, including the occurrence of major adverse cardiac events (MACE) (comprising MI, cardiac death, and TLR), TLR, and all-cause mortality. Additionally, the study assessed the prevalence of restenosis and thrombosis of the investigated lesion and health economic endpoints, such as contrast volume and cumulative radiation dose during PCI. TLR was defined as the repeat PCI of the target lesion or bypass surgery of the target vessel performed because of restenosis or other complications of the target lesion. The target lesion was the treated segment, including the 5-mm margin proximal and distal to the stent. MI was diagnosed following the Fourth Universal Definition of Myocardial Infarction [14] . 2.3 Statistical analysis The analyses used statistical software R. The nonparametric two-sample Mann–Whitney U test was used for continuous variables and Fisher’s exact test for categorical variables to compare subjects between groups. The statistical significance cut-off point was set at 0.05, and lower p-values were considered significant. Data on 1-year follow-ups were available for all patients. The Kaplan–Meier curves depict the cumulative 1-year TLF, MACE, all-cause death, and TLR rates in the groups, which were compared using the log-rank test. 3. Results 3.1 Patient characteristics Table 1 shows all patient characteristic data. The average age of patients in both groups Table 1 Baseline patient characteristics DK Culotte group (n = 117) Culotte group (n = 122) p-value Age, years 66,91 ± 9.4 66.46 ± 9.1 0.709 Male sex 88 (75.2%) 85 (69.7%) 0.386 Clinical presentation Unstable angina 56 (47.86%) 43 (35.25%) 0.050 NSTEMI 41 (35.04%) 55 (45.08%) 0.146 STEMI 20 (17.09%) 24 (19.67%) 0.621 Clinical history Diabetes mellitus type 2 36 (30.77%) 58 (47.54%) 0.008 Insulin-dependent Diabetes 10 (8.54%) 12 (9.84%) 0.824 Hypertension 94 (80.34%) 103 (84.43%) 0.496 Hyperlipidemia 98 (83.76%) 91 (74.59%) 0.111 Atrial Fibrillation 13 (11.11%) 27 (22.13%) 0.025 Current smoking 36 (30.77%) 45 (36.89%) 0.341 COPD/Asthma Bronchial 5 (4.27%) 14 (11.48%) 0.054 Previous PCI 37 (31.62%) 42 (34.43%) 0.681 Previous MI 34 (29.06%) 30 (24.59%) 0.467 Previous CABG 3 (2.56%) 7 (5.73%) 0.334 Dialysis 2 (1.71%) 1 (0.82%) 0.616 Ischemic stroke/TIA history 4 (3.41%) 10 (8.20%) 0.168 LVEF, % 56 [45–63] 55 [40–60] 0.037 Laboratory values Total cholesterol, mmol/L 4.6 [3.9–5.5] 4.6 [3.95–5.85] 0.321 LDL, mmol/L 2.6 [1.9–3.4] 2.7 [1.9–3.63] 0.279 HDL, mmol/L 1.2 [1.0–1.4] 1.2 [1.0–1.5] 0.953 Hemoglobin, baseline, g/dL 14.1 [13.1–15.1] 14.2 [13.1–14.9] 0.809 Creatine, µmol/l 82.0 [68.8–96.5] 85.7 [72.0–100.0] 0.283 Antiplatelets and anticoagulants at discharge ASA 117 (100%) 122 (100%) N/A Clopidorel 68 (58.12%) 83 (68.03%) 0.140 Tikagrelor 43 (36.75%) 38 (31.15%) 0.413 Prasugrel 4 (3.42%) 0 (0.0%) 0.056 NOAC 13 (11.11%) 20 (16.39%) 0.264 VKA 3 (2.56%) 6 (4.92%) 0.500 Values are n (%), mean ± SD or median [interquartile range]; ASA: acetylosalicylic acid; CABG: coronary artery bypass graft; COPD: chronic obstructive pulmonary disease; DK: double kiss; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LVEF: left ventricular ejection fraction; MI myocardial infarction; N/A: not applicable; NOAC: novel oral anticoagulant; PCI: percutaneous coronary intervention; SD: standard deviation; TIA: transient ischemic attack, VKA: vitamin K antagonists was 66 years, with a predominance of males in each group (DK culotte group: 75.2% and culotte group: 69.7%). The prevalence of unstable angina among patients was higher in the DK culotte group (47.86% vs. 35.25%, p = 0.050). Among all comorbidities, diabetes mellitus type 2 and atrial fibrillation were observed less frequently in the DK culotte group compared to the culotte group (30.77% vs. 47.54%, p = 0.008 for diabetes mellitus type 2 and 11.11% vs. 22.13%, p = 0.025 for atrial fibrillation). The prevalence of lipidemic disorders was similar in both groups. No significant differences in the discharge regimens of antiplatelet and anticoagulant medications were found. 3.2 Lesions and procedural characteristics The complexity of CAD, as assessed by the SYNTAX score, was similar across both groups (DK culotte median: 15.0 points vs. culotte median: 16.5 points). However, the DK culotte group demonstrated a significantly better prognosis, as evaluated by the Logistic SYNTAX score and SYNTAX II (p = 0.037 and p = 0.017, respectively). The use of the two-stent technique as a bail-out strategy was relatively infrequent, accounting for 7.69% and 7.38% of PCI’s in the DK culotte and culotte groups, respectively. The most frequently used technique was the inverted stenting technique, which involves stenting the SB first in both groups (DK culotte group: 84.62% and culotte group: 84.43%). The DK culotte resulted in a 100% success rate for the final KB inflation procedure, compared with 97.54% in the culotte group. Patients in the DK culotte group underwent post-stent implantation proximal optimization technique (POT) more often after the first stent deployment (89.74% vs 45.08%; p < 0.001), and a higher incidence of final POT was observed (94.87% vs. 79.8%; p < 0.001). Both groups demonstrated a low levels of image-guided PCI. Table 2 shows detailed procedural-related data. Table 2 Baseline angiographic and procedural characteristics. DK Culotte group (n = 117) Culotte group (n = 122) p-value Vessel and clinical assessment: SYNTAX Score I 15 [11–21] 16.5 [12–26] 0.120 Logistic SYNTAX Score 2.9 [1.5–5.5] 4.2 [1.6–11.0] 0.037 PCI SYNTAX Score II 28.6 [22.1–39.3] 32.95 [25.4–44.68] 0.017 Bifurcation lesion location : LM 47 (40.17%) 41 (33.61%) 0.294 non-LM (LAD/D) 48 (41.03%) 43 (35.25%) 0.359 non-LM (Cx/OM) 17 (14.53%) 31 (25.41%) 0.036 non-LM (RCA/PLA) 5 (4.27%) 7 (5.74%) 0.607 PCI access : Femoral access 18 (15.38%) 20 (16.39%) 0.832 Radial access 99 (84.62%) 102 (83.61%) 0.833 Procedure characteristics : Bail out two stent strategy 9 (7.69%) 9 (7.38%) 0.927 Side branch stent diameter, mm 3.0 [2.75–3.0] 3.0 [2.5–3.5] 0.996 Side branch stent length, mm 20 [18–26] 22 [18–28] 0.156 Main branch stent diameter, mm 4.0 [3.0–3.5] 4.0 [3.0–3.5] 0.361 Main branch stent length, mm 25 [18–26] 26 [18–30] 0.624 Stent to the side branch first 99 (84.62%) 103 (84.43%) 0.968 Side branch predilatation 97 (82.90%) 102 (83.60%) 0.885 Main branch predilatation 85 (72.65%) 106 (86.89%) 0.005 Pre POT 105 (89.74%) 55 (45.08%) < 0.001 KB after the first stent implantation 117 (100%) 0 (0.0%) N/A KB after the second stent implantation 117 (100%) 119 (97.54%) N/A Final POT 111 (94.87%) 98 (79.50%) < 0.001 IVUS/OCT imaging 16 (13.68%) 5 (4.10%) 0.008 Rotablation 5 (4.27%) 6 (4.92%) 0.813 Intravascular lithotripsy 2 (1.71%) 1 (0.82%) 0.539 GP IIb/IIIa use 2 (1.71%) 11 (9.02%) 0.013 Radiation dose (mGy) 1868 [1178–2891] 2114.5 [1372.5–3265] 0.127 Contrast media amount (mL) 220 [170–280] 230 [200–270] 0.214 Values are n (%), mean ± SD or median [interquartile range]. Cx: circumflex; D: diagonal; DK: double kiss; GP: glycoprotein; IVUS: intravascular ultrasound; KB: kissing balloon; LAD: left anterior descending; LM: left main; OCT: optical coherence tomography; OM: obtuse marginal; PCI: percutaneous coronary intervention; N/A: not applicable; PLA: posterolateral artery; POT: proximal optimization technique; RCA: right coronary artery; RVA: right ventricular artery; SD: standard deviation 3.3 Clinical outcomes Table 3 shows the clinical results. The analysis of the TLF rate at the 1-year follow-up did not show a statistically significant difference in outcomes between the two study cohorts, despite noticeable numerical differences in favor of the DK Culotte. This follow-up point revealed TLF in 6.84% and 13.11% of patients in the DK culotte group and culotte groups, respectively (p = 0.085). None of the patients who received bail-out strategy treatment in either group experienced the primary endpoint. The incidence of stent restenosis was similar in both groups (3.42% vs. 6.55, p = 0.269). The central illustration presents the Kaplan-Meier curves, demonstrating the TLF, MACE, all cause death and TLR survival rates. The analysis of secondary endpoints for MACE also did not reach statistical significance, despite a clear favorable trend for the DK Culotte (12.82% vs. 19.67%; p = 0.073). Kaplan-Meier curves for the secondary endpoints are attached in the central illustration. The contrast volume used and cumulative radiation dose during PCI were comparable (see Fig. 1 ). Table 3 Clinical outcome summary DK Culotte group (n = 117) Culotte group (n = 122) p-value 1 – year follow up primary outcome: Primary outcome: Target lesion failure (cardiac death, target vessel myocardial infarct, target lesion revascularisation) 8 (6.84%) 16 (13.11%) 0.085 1 – year follow up secondary outcome : Principal secondary outcome: MACE (myocardial infarct, cardiac death, target lesion revascularisation) 15 (12.82%) 24 (19.67%) 0.073 Target lesion-revascularisation 6 (5.13%) 11 (9.02%) 0.183 All - cause mortality 6 (5.13%) 9 (7.38%) 0.446 Stent thrombosis 4 (3.42%) 4 (3.28%) 0.954 Stent restenosis 4 (3.42%) 8 (6.55%) 0.269 Values are n (%); MACE: major adverse cardiac events 4. Discussion To the best of our knowledge, this study is the first to investigate clinical outcomes following treatment of bifurcation lesions using two different 2-stent techniques, DK culotte versus culotte, in a real-life ACS cohort. The study results did not show a statistically significant difference between the two stent techniques in terms of 1-year follow-up. However, there was a trend towards a lower incidence of 1-year TLF and MACE in the DK culotte group compared to the classic culotte group, primarily due to a lower number of TLR events. Statistical significance could have been achieved with a longer follow-up period or larger study groups. Additionally, no significant differences in contrast volume or radiation dose were found between the two evaluated stenting techniques. The DK culotte technique facilitated achieving a 100% success rate in the final-KB procedure. According to the revascularization guidelines [15] , provisional stenting is the most applicable solution in most bifurcation cases. However, operators may need to consider a two-stent technique in more complex coronary bifurcation anatomies, especially in the ACS subset where preserving good flow to the SB may be crucial to achieve a favorable clinical outcome and potentially reduce ischemic burden. Several anatomical features may encourage this approach. Procedural factors that influence the adoption of up-front two-stent strategies include a large SB (≥ 2.75 mm) with a long ostial lesion (at least > 5 mm), anticipated difficulty in accessing the SB after MB stenting, and true bifurcation lesions [16, 17] . Recently published data indicate that a systematic two-stent approach may be associated with a significant improvement in clinical outcomes compared with classical single-stent technique in patients with complex bifurcation lesions [18] . The bifurcation consensus document [3] by the European Bifurcation Club listed three main two-stent techniques: “T/TAP”, “culotte”, and “DK-crush”. Since the development of DK-crush by Chen et al. [19] , several landmark trials have demonstrated the safety and efficacy of this technique, particularly compared with classic crush. A modification to the classic crush technique, involving the addition of an extra KB inflation, has significantly improved the long-term results of the DK crush. Various studies revealed that KB inflation is a crucial aspect of bifurcation management. Since its introduction to clinical practice [7] , the technically demanding bifurcation stenting technique known as Culotte, has become widely used because of its satisfactory safety and efficiency [8,20] . However, some data indicate that the DK-culotte technique may provide benefits over culotte [21, 22] . Recent bench testing reveals that performing additional KB dilatation before stenting the second branch may improve the culotte technique [10] . This reduces the risk of pulling the struts of the first stent toward the ostium, which could affect the procedure's progress and the ability to perform a final KB inflation. The latter is crucial for achieving optimal results. Therefore, this simple modification is a new cornerstone for improving the culotte technique. However, clinical studies that investigate the significant effects of adding KB to culotte technique, on long-term outcomes remain lacking. The results of this multicentre retrospective analysis are the first available data on the short-term prognosis of the DK Culotte method compared to the Culotte method. Additional KB step is a safe method for modifying the Culotte technique facilitating the performance of the final KB procedure. Further follow-up is recommended to determine any distant benefits. 5. Limitations When interpreting the results of this study, it is important to consider the study's limitations. The primary limitation is its observational nature, which resulted in heterogeneity among the study groups. This was particularly evident in the cases involving type 2 diabetes mellitus, atrial fibrillation, intravascular imaging with OCT/IVUS, and the complexity of the coronary pathology assessed by the SYNTAX Logistic Score and SYNTAX II. This heterogeneity may introduce significant constraints in the interpretation of the results and their generalizability. Additionally, statistical significance was not achieved despite a clear trend favoring the the DK crush technique, possibly due to the small size of the study group. Various guidelines were in place regarding dual antiplatelet and antithrombotic therapy from 2013 to 2022 (registry scope), which may influenced adverse cardiovascular events in patients undergoing the two-stent technique. However, the presented data are still useful in the absence of any information regarding the DK crush technique. 6. Conclusions In our study, numerical superiority for reducing TLF and MACE was observed in patients treated with the DK-Culotte, although statistical significance was not reached (p = 0.085 and p = 0.073, respectively). Additionally, the DK Culotte modification did not result in increased contrast medium usage or cumulative radiation dosage. Abbreviations ACS – acute coronary syndrome DK culotte – double-kissing culotte KB – kissing balloon MACE - major adverse cardiac events PCI – percutaneous coronary intervention TLF – target lesion failure Declarations Declaration of Interest statement All authors have no conflicts of interest to disclose. Data availability statement The information and data of the study population were extracted from the Hospital Information System. The datasets are not publicly available because the individual privacy of the patients should be protected. However, the data are available from the corresponding author upon reasonable request. Funding No funding was received. Author Contributions statement The authors confirm contribution to the paper as follows: study conception and design: M.B., P.R, A.W., M.L, A.D.; data collection: Sz.W., P.W, M.B., P.R., Ł.F., A.J., M.P. analysis and interpretation of results: M.B., K.G., P.R., A.D., M.L.; draft manuscript preparation: M.B. Sz.W, P.R, M.L, A.J., M.P. All authors reviewed the results and approved the final version of the manuscript. References Steigen, TK. et al . Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation . 114,1955-1961 (2006). Elwany, M., Palma GD., Cortese B. Treatment of coronary bifurcation lesions: current knowledge and future perspectives. Future Cardiol . 14, 165-179 (2018). Albiero, R. et al. Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club. 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Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol . 61, 1482-1488 (2013). Chen, SL. et al. Clinical Outcome After DK Crush Versus Culotte Stenting of Distal Left Main Bifurcation Lesions: The 3-Year Follow-Up Results of the DKCRUSH-III Study. JACC Cardiovasc Interv . 8, 1335-1342 (2015). Additional Declarations No competing interests reported. Supplementary Files floatimage1.jpeg CENTRAL ILLUSTRATION. Cite Share Download PDF Status: Published Journal Publication published 03 Dec, 2024 Read the published version in Journal of Clinical Medicine → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4338717","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":299480312,"identity":"26a54f26-7d88-4265-8668-d34fdf739d6a","order_by":0,"name":"Mateusz Barycki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBCDBBDB2GBgA6IaD+BXzIyiJQ1MkaKF4TCYh1eLbvv5g495/tTl8c8+Y/hxRsF5u7Xth4G21NhE49JidiaZ2Zi3ja1Y4lyOseQGg9vJ284kArUcS8ttwKXlQDKbNG8DT2LDGR4zxgdALWYHgFoYGw7j1nL+Mftvnj8SifMhWs4lm51/SEDLjWQ2Zh42g8QNIC0bDA7Ymd0gZMuNx8aSc9sSig3PsBVLzjBITjC7AbQlAZ9fzic+/PAGGGJyZ5g3fuz5Y2dvdj794YMPNTY4tSABDgMQmQhWmUBYOQiwPwCR9sQpHgWjYBSMgpEEAHI2ZLxLT/DkAAAAAElFTkSuQmCC","orcid":"","institution":"Provincial Specialized Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mateusz","middleName":"","lastName":"Barycki","suffix":""},{"id":299480313,"identity":"b2ac4580-1c99-4a9a-98bd-11afd51ea2fa","order_by":1,"name":"Adrian Włodarczak","email":"","orcid":"","institution":"The Copper Health Centre (MCZ)","correspondingAuthor":false,"prefix":"","firstName":"Adrian","middleName":"","lastName":"Włodarczak","suffix":""},{"id":299480314,"identity":"e1e73083-9775-4bc1-87f8-4ec71156408d","order_by":2,"name":"Piotr Rola","email":"","orcid":"","institution":"Provincial Specialized Hospital","correspondingAuthor":false,"prefix":"","firstName":"Piotr","middleName":"","lastName":"Rola","suffix":""},{"id":299480315,"identity":"27754b2a-4106-4ef3-82d5-4c9a6d091fbc","order_by":3,"name":"Szymon Włodarczak","email":"","orcid":"","institution":"The Copper Health Centre (MCZ)","correspondingAuthor":false,"prefix":"","firstName":"Szymon","middleName":"","lastName":"Włodarczak","suffix":""},{"id":299480316,"identity":"19057eb8-2b39-4fd8-9a0f-194b5457735c","order_by":4,"name":"Maciej Pęcherzewski","email":"","orcid":"","institution":"The Copper Health Centre (MCZ)","correspondingAuthor":false,"prefix":"","firstName":"Maciej","middleName":"","lastName":"Pęcherzewski","suffix":""},{"id":299480317,"identity":"bcfc451e-02af-4712-9070-eccc109a91f9","order_by":5,"name":"Piotr Włodarczak","email":"","orcid":"","institution":"The Copper Health Centre (MCZ)","correspondingAuthor":false,"prefix":"","firstName":"Piotr","middleName":"","lastName":"Włodarczak","suffix":""},{"id":299480318,"identity":"22e7d9c5-ed80-4586-be01-7a1c41388fb0","order_by":6,"name":"Artur Jastrzębski","email":"","orcid":"","institution":"The Copper Health Centre (MCZ)","correspondingAuthor":false,"prefix":"","firstName":"Artur","middleName":"","lastName":"Jastrzębski","suffix":""},{"id":299480319,"identity":"14a3e5b8-135a-4018-9aff-3847cb900594","order_by":7,"name":"Łukasz Furtan","email":"","orcid":"","institution":"Provincial Specialized Hospital","correspondingAuthor":false,"prefix":"","firstName":"Łukasz","middleName":"","lastName":"Furtan","suffix":""},{"id":299480320,"identity":"99647bf9-15a0-423f-9ba4-56c5a64bde06","order_by":8,"name":"Katarzyna Giniewicz","email":"","orcid":"","institution":"Professional Medical Statistician","correspondingAuthor":false,"prefix":"","firstName":"Katarzyna","middleName":"","lastName":"Giniewicz","suffix":""},{"id":299480321,"identity":"d5703470-681b-456a-b8e2-e013dce3971e","order_by":9,"name":"Adrian Doroszko","email":"","orcid":"","institution":"Wroclaw University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Adrian","middleName":"","lastName":"Doroszko","suffix":""},{"id":299480322,"identity":"3eeec6f0-ac3e-4d88-8a96-1f9d2fba03b9","order_by":10,"name":"Maciej Lesiak","email":"","orcid":"","institution":"University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Maciej","middleName":"","lastName":"Lesiak","suffix":""}],"badges":[],"createdAt":"2024-04-28 16:25:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4338717/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4338717/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3390/jcm13237392","type":"published","date":"2024-12-04T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56196417,"identity":"69c9c94a-f4be-4304-adfb-b969e8342ae3","added_by":"auto","created_at":"2024-05-09 18:10:30","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":163141,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContrast media amount and radiation used during PCI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePCI - percutaneous coronary intervention\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4338717/v1/8111b2227396946526da14cd.jpeg"},{"id":71572330,"identity":"859c7d3e-3d09-40be-906c-ea18163a03ce","added_by":"auto","created_at":"2024-12-16 19:51:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":848543,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4338717/v1/51ea8245-dca7-4953-8a1a-58bc171094b7.pdf"},{"id":56196470,"identity":"63b4587e-327d-4b3a-9362-3c97893e0578","added_by":"auto","created_at":"2024-05-09 18:10:46","extension":"jpeg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1194115,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCENTRAL ILLUSTRATION.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4338717/v1/8258d70c291141c98f23610e.jpeg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative short-term outcomes of double-kissing culotte and culotte techniques in acute coronary syndrome: A Multicenter Retrospective Study","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eBifurcation lesions remain a complex challenge for interventional cardiologists despite significant advances in the devices and techniques used in percutaneous coronary intervention (PCI). These lesions are relatively prevalent, accounting for 15\u0026ndash;20% of all PCI cases\u003csup\u003e[1]\u003c/sup\u003e. The provisional stenting technique has recently shown more consistent results, but due to the diversity and complexity of the anatomical subset in bifurcation lesions, a single stent strategy may cause the loss of functionally significant side branches, affecting short and long-term outcomes\u003csup\u003e[2, 3]\u003c/sup\u003e. This challenging scenario is frequently related to so-called \u0026ldquo;true\u0026rdquo; bifurcations, where both the main branch (MB) and side branch (SB) are significantly narrowed (\u0026gt;\u0026thinsp;50% diameter stenosis) and \u0026ldquo;non-true\u0026rdquo; bifurcations, which include all the other lesions involving a bifurcation\u003csup\u003e[4]\u003c/sup\u003e. Two-stent techniques have been introduced into clinical practice to address these anatomical obstacles. However, these techniques distort the stent structure in the bifurcation area and, depending on the technique used may result in the placement of two or even three layers of metal struts against the vessel wall. This could significantly affect postoperative outcomes, particularly in a highly thrombotic subset of acute coronary syndromes (ACS). The optimal technique for two-stent PCI is currently a topic of ongoing debate, with increasing data available on this subject \u003csup\u003e[5, 6]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe culotte technique, introduced by Chevalier\u003csup\u003e[7]\u003c/sup\u003e, is a well-established two-stent procedure that has demonstrated a favorable safety profile and positive clinical outcomes\u003csup\u003e[8, 9]\u003c/sup\u003e. Despite its firmly established role in the PCI armamentarium, recent bench test data\u003csup\u003e[10]\u003c/sup\u003e indicate that a modification to this technique, known as the Double Kissing (DK) culotte could facilitate the procedure's performance and potentially improve clinical outcomes. The DK-culotte technique is a variation of the classical culotte technique characterized by an additional kissing balloon (KB) inflation that follows SB stenting (inverted technique) or MB stenting (conventional technique) and precedes the second branch stent implantation. This additional step reduces the risk of the first implanted stent's struts being pulled towards the ostium when deploying the second stent. During the culotte technique, pulling the struts may result in incomplete coverage of the ostium after the final KB if the rewiring was performed incorrectly. There is a lack of data regarding the outcomes of the DK culotte technique, with only a few case reports available\u003csup\u003e[11, 12]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBased on these preliminary insights and the need for further clinical validation, it is hypothesized that the DK-Culotte technique may offer better clinical outcomes than the standard Culotte technique.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study population\u003c/h2\u003e \u003cp\u003eThe Lower Silesia culotte Bifurcation Registry (LSCBR) is a multicenter retrospective analysis aimed at assessing the short-term outcomes of bifurcation PCI in patients with ACS using two different techniques, DK culotte and culotte. This study retrospectively analyzed subjects who underwent PCI in two high-volume cooperative Cardiac Departments in the Lower Silesia Region (Poland) from September 2013 to December 2022, during ACS. During these periods, all PCI data were screened for bifurcation lesions that were responsible for ACS and required subsequent two-stent implantation. A total of 117 patients were assigned to the DK-culotte group, and 122 patients were assigned to the control culotte group (see Central Illustration). Patients who qualified for the two-stent technique a priori and those who required a second stent as a bail-out strategy after the provisional approach were eligible for the registry. The decision to perform PCI was based on clinical indications, such as ongoing ischemia, significant angiographic coronary artery disease (CAD) that is suitable for PCI under the European Society of Cardiology recommendations, patient preference against alternative treatment options, or the decision of the Heart Team. The decision to perform PCI with the selected two-stent technique with second- and third-generation drug-eluting stents (DES) was left to the interventional cardiologist\u0026rsquo;s discretion based on clinical and angiographic features. The analysis excluded patients who had undergone PCI with coronary stenting of the bifurcation lesion under investigation before the index procedure or suffered prehospital cardiac arrest. No vessel-related exclusion criteria were applied.\u003c/p\u003e \u003cp\u003e The Bioethics Committee of the Lower Silesian Medical Association (Poland) approved this study (01/BO/2023). All patients were fully informed of all treatment options and risks associated with PCI before signing written consent for the procedure. Informed consent was obtained from all individual participants included in the study for both participation and the publication of identifying information/images. This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. This study was registered in the ClinicalTrials.gov database under registration number NCT06284057.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study endpoints\u003c/h2\u003e \u003cp\u003eThe study\u0026rsquo;s primary endpoint was target lesion failure (TLF), which is a composite of cardiovascular (CV) death, target vessel myocardial infarction (TV-MI), or clinically driven target lesion revascularization (TLR) at the 1-year follow-up\u003csup\u003e[13]\u003c/sup\u003e. Additionally, the study evaluated the prevalence of secondary endpoints, including the occurrence of major adverse cardiac events (MACE) (comprising MI, cardiac death, and TLR), TLR, and all-cause mortality. Additionally, the study assessed the prevalence of restenosis and thrombosis of the investigated lesion and health economic endpoints, such as contrast volume and cumulative radiation dose during PCI. TLR was defined as the repeat PCI of the target lesion or bypass surgery of the target vessel performed because of restenosis or other complications of the target lesion. The target lesion was the treated segment, including the 5-mm margin proximal and distal to the stent. MI was diagnosed following the Fourth Universal Definition of Myocardial Infarction\u003csup\u003e[14]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe analyses used statistical software R. The nonparametric two-sample Mann\u0026ndash;Whitney U test was used for continuous variables and Fisher\u0026rsquo;s exact test for categorical variables to compare subjects between groups. The statistical significance cut-off point was set at 0.05, and lower p-values were considered significant. Data on 1-year follow-ups were available for all patients. The Kaplan\u0026ndash;Meier curves depict the cumulative 1-year TLF, MACE, all-cause death, and TLR rates in the groups, which were compared using the log-rank test.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Patient characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows all patient characteristic data. The average age of patients in both groups\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline patient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK Culotte group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCulotte group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;122)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66,91\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.46\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.709\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (75.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (69.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnstable angina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u0026nbsp;(47.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (35.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSTEMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (35.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (45.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTEMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (17.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (19.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus type 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (30.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (47.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsulin-dependent Diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (8.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (9.84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.824\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (80.34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (84.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (83.76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (74.59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial Fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (11.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (22.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (30.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (36.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD/Asthma Bronchial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (11.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious PCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (31.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (34.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.681\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious MI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (29.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (24.59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious CABG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.616\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic stroke/TIA history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (8.20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 [45\u0026ndash;63]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 [40\u0026ndash;60]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaboratory values\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal cholesterol, mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6 [3.9\u0026ndash;5.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.6 [3.95\u0026ndash;5.85]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDL, mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6 [1.9\u0026ndash;3.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7 [1.9\u0026ndash;3.63]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDL, mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 [1.0\u0026ndash;1.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2 [1.0\u0026ndash;1.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin, baseline, g/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.1 [13.1\u0026ndash;15.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.2 [13.1\u0026ndash;14.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatine, \u0026micro;mol/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.0 [68.8\u0026ndash;96.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.7 [72.0\u0026ndash;100.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntiplatelets and anticoagulants at discharge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClopidorel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (58.12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (68.03%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTikagrelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (36.75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (31.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.413\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrasugrel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNOAC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (11.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (16.39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eValues are n (%), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median [interquartile range]; ASA: acetylosalicylic acid; CABG: coronary artery bypass graft; COPD: chronic obstructive pulmonary disease; DK: double kiss; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LVEF: left ventricular ejection fraction; MI myocardial infarction;\u0026nbsp;N/A: not applicable;\u0026nbsp;NOAC: novel oral anticoagulant; PCI: percutaneous coronary intervention; SD: standard deviation; TIA: transient ischemic attack, VKA: vitamin K antagonists\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003ewas 66 years, with a predominance of males in each group (DK culotte group: 75.2% and culotte group: 69.7%). The prevalence of unstable angina among patients was higher in the DK culotte group (47.86% vs. 35.25%, p\u0026thinsp;=\u0026thinsp;0.050). Among all comorbidities, diabetes mellitus type 2 and atrial fibrillation were observed less frequently in the DK culotte group compared to the culotte group (30.77% vs. 47.54%, p\u0026thinsp;=\u0026thinsp;0.008 for diabetes mellitus type 2 and 11.11% vs. 22.13%, p\u0026thinsp;=\u0026thinsp;0.025 for atrial fibrillation). The prevalence of lipidemic disorders was similar in both groups. No significant differences in the discharge regimens of antiplatelet and anticoagulant medications were found.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Lesions and procedural characteristics\u003c/h2\u003e \u003cp\u003eThe complexity of CAD, as assessed by the SYNTAX score, was similar across both groups (DK culotte median: 15.0 points vs. culotte median: 16.5 points). However, the DK culotte group demonstrated a significantly better prognosis, as evaluated by the Logistic SYNTAX score and SYNTAX II (p\u0026thinsp;=\u0026thinsp;0.037 and p\u0026thinsp;=\u0026thinsp;0.017, respectively). The use of the two-stent technique as a bail-out strategy was relatively infrequent, accounting for 7.69% and 7.38% of PCI\u0026rsquo;s in the DK culotte and culotte groups, respectively. The most frequently used technique was the inverted stenting technique, which involves stenting the SB first in both groups (DK culotte group: 84.62% and culotte group: 84.43%). The DK culotte resulted in a 100% success rate for the final KB inflation procedure, compared with 97.54% in the culotte group. Patients in the DK culotte group underwent post-stent implantation proximal optimization technique (POT) more often after the first stent deployment (89.74% vs 45.08%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a higher incidence of final POT was observed (94.87% vs. 79.8%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Both groups demonstrated a low levels of image-guided PCI. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows detailed procedural-related data.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline angiographic and procedural characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK Culotte group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCulotte group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;122)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eVessel and clinical assessment:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSYNTAX Score I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 [11\u0026ndash;21]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.5 [12\u0026ndash;26]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLogistic SYNTAX Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 [1.5\u0026ndash;5.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2 [1.6\u0026ndash;11.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI SYNTAX Score II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.6 [22.1\u0026ndash;39.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.95 [25.4\u0026ndash;44.68]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBifurcation lesion location\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (40.17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (33.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-LM (LAD/D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (41.03%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (35.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-LM (Cx/OM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (14.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (25.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-LM (RCA/PLA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCI access\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (15.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (16.39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadial access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (84.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (83.61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedure characteristics\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBail out two stent strategy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (7.69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (7.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide branch stent diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0 [2.75\u0026ndash;3.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 [2.5\u0026ndash;3.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide branch stent length, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 [18\u0026ndash;26]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 [18\u0026ndash;28]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain branch stent diameter, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0 [3.0\u0026ndash;3.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0 [3.0\u0026ndash;3.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain branch stent length, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 [18\u0026ndash;26]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 [18\u0026ndash;30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.624\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent to the side branch first\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (84.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (84.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.968\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide branch predilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (82.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (83.60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.885\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain branch predilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (72.65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106 (86.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre POT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (89.74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (45.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKB after the first stent implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKB after the second stent implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119 (97.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal POT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (94.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (79.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVUS/OCT imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (13.68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotablation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravascular lithotripsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.539\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGP IIb/IIIa use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.02%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation dose (mGy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1868 [1178\u0026ndash;2891]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2114.5 [1372.5\u0026ndash;3265]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContrast media amount (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e220 [170\u0026ndash;280]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e230 [200\u0026ndash;270]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eValues are n (%), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median [interquartile range]. Cx: circumflex; D: diagonal; DK: double kiss; GP: glycoprotein; IVUS: intravascular ultrasound; KB: kissing balloon; LAD: left anterior descending; LM: left main; OCT: optical coherence tomography; OM: obtuse marginal; PCI: percutaneous coronary intervention; N/A: not applicable;\u0026nbsp; PLA: posterolateral artery; POT: proximal optimization technique; RCA: right coronary artery; RVA: right ventricular artery;\u0026nbsp; SD: standard deviation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Clinical outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the clinical results. The analysis of the TLF rate at the 1-year follow-up did not show a statistically significant difference in outcomes between the two study cohorts, despite noticeable numerical differences in favor of the DK Culotte. This follow-up point revealed TLF in 6.84% and 13.11% of patients in the DK culotte group and culotte groups, respectively (p\u0026thinsp;=\u0026thinsp;0.085). None of the patients who received bail-out strategy treatment in either group experienced the primary endpoint. The incidence of stent restenosis was similar in both groups (3.42% vs. 6.55, p\u0026thinsp;=\u0026thinsp;0.269). The central illustration presents the Kaplan-Meier curves, demonstrating the TLF, MACE, all cause death and TLR survival rates. The analysis of secondary endpoints for MACE also did not reach statistical significance, despite a clear favorable trend for the DK Culotte (12.82% vs. 19.67%; p\u0026thinsp;=\u0026thinsp;0.073). Kaplan-Meier curves for the secondary endpoints are attached in the central illustration. The contrast volume used and cumulative radiation dose during PCI were comparable (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcome summary\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDK Culotte group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCulotte group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;122)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e1 \u0026ndash; year follow up primary outcome:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary outcome: Target lesion failure (cardiac death, target vessel myocardial infarct, target lesion revascularisation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6.84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (13.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 \u0026ndash; year follow up secondary outcome\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrincipal secondary outcome: MACE (myocardial infarct, cardiac death, target lesion revascularisation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (12.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (19.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTarget lesion-revascularisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.02%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll - cause mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (7.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent thrombosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3.28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent restenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eValues are n (%); MACE: major adverse cardiac events\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTo the best of our knowledge, this study is the first to investigate clinical outcomes following treatment of bifurcation lesions using two different 2-stent techniques, DK culotte versus culotte, in a real-life ACS cohort.\u003c/p\u003e \u003cp\u003eThe study results did not show a statistically significant difference between the two stent techniques in terms of 1-year follow-up. However, there was a trend towards a lower incidence of 1-year TLF and MACE in the DK culotte group compared to the classic culotte group, primarily due to a lower number of TLR events. Statistical significance could have been achieved with a longer follow-up period or larger study groups. Additionally, no significant differences in contrast volume or radiation dose were found between the two evaluated stenting techniques. The DK culotte technique facilitated achieving a 100% success rate in the final-KB procedure.\u003c/p\u003e \u003cp\u003eAccording to the revascularization guidelines\u003csup\u003e[15]\u003c/sup\u003e, provisional stenting is the most applicable solution in most bifurcation cases. However, operators may need to consider a two-stent technique in more complex coronary bifurcation anatomies, especially in the ACS subset where preserving good flow to the SB may be crucial to achieve a favorable clinical outcome and potentially reduce ischemic burden. Several anatomical features may encourage this approach. Procedural factors that influence the adoption of up-front two-stent strategies include a large SB (\u0026ge;\u0026thinsp;2.75 mm) with a long ostial lesion (at least\u0026thinsp;\u0026gt;\u0026thinsp;5 mm), anticipated difficulty in accessing the SB after MB stenting, and true bifurcation lesions \u003csup\u003e[16, 17]\u003c/sup\u003e. Recently published data indicate that a systematic two-stent approach may be associated with a significant improvement in clinical outcomes compared with classical single-stent technique in patients with complex bifurcation lesions\u003csup\u003e[18]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe bifurcation consensus document\u003csup\u003e[3]\u003c/sup\u003e by the European Bifurcation Club listed three main two-stent techniques: \u0026ldquo;T/TAP\u0026rdquo;, \u0026ldquo;culotte\u0026rdquo;, and \u0026ldquo;DK-crush\u0026rdquo;. Since the development of DK-crush by Chen et al.\u003csup\u003e[19]\u003c/sup\u003e, several landmark trials have demonstrated the safety and efficacy of this technique, particularly compared with classic crush. A modification to the classic crush technique, involving the addition of an extra KB inflation, has significantly improved the long-term results of the DK crush. Various studies revealed that KB inflation is a crucial aspect of bifurcation management.\u003c/p\u003e \u003cp\u003eSince its introduction to clinical practice\u003csup\u003e[7]\u003c/sup\u003e, the technically demanding bifurcation stenting technique known as Culotte, has become widely used because of its satisfactory safety and efficiency\u003csup\u003e[8,20]\u003c/sup\u003e. However, some data indicate that the DK-culotte technique may provide benefits over culotte\u003csup\u003e[21, 22]\u003c/sup\u003e. Recent bench testing reveals that performing additional KB dilatation before stenting the second branch may improve the culotte technique\u003csup\u003e[10]\u003c/sup\u003e. This reduces the risk of pulling the struts of the first stent toward the ostium, which could affect the procedure's progress and the ability to perform a final KB inflation. The latter is crucial for achieving optimal results.\u003c/p\u003e \u003cp\u003eTherefore, this simple modification is a new cornerstone for improving the culotte technique. However, clinical studies that investigate the significant effects of adding KB to culotte technique, on long-term outcomes remain lacking. The results of this multicentre retrospective analysis are the first available data on the short-term prognosis of the DK Culotte method compared to the Culotte method. Additional KB step is a safe method for modifying the Culotte technique facilitating the performance of the final KB procedure. Further follow-up is recommended to determine any distant benefits.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eWhen interpreting the results of this study, it is important to consider the study's limitations. The primary limitation is its observational nature, which resulted in heterogeneity among the study groups. This was particularly evident in the cases involving type 2 diabetes mellitus, atrial fibrillation, intravascular imaging with OCT/IVUS, and the complexity of the coronary pathology assessed by the SYNTAX Logistic Score and SYNTAX II. This heterogeneity may introduce significant constraints in the interpretation of the results and their generalizability. Additionally, statistical significance was not achieved despite a clear trend favoring the the DK crush technique, possibly due to the small size of the study group. Various guidelines were in place regarding dual antiplatelet and antithrombotic therapy from 2013 to 2022 (registry scope), which may influenced adverse cardiovascular events in patients undergoing the two-stent technique. However, the presented data are still useful in the absence of any information regarding the DK crush technique.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eIn our study, numerical superiority for reducing TLF and MACE was observed in patients treated with the DK-Culotte, although statistical significance was not reached (p\u0026thinsp;=\u0026thinsp;0.085 and p\u0026thinsp;=\u0026thinsp;0.073, respectively). Additionally, the DK Culotte modification did not result in increased contrast medium usage or cumulative radiation dosage.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACS \u0026ndash; acute coronary syndrome\u003c/p\u003e\n\u003cp\u003eDK culotte \u0026ndash; double-kissing culotte\u003c/p\u003e\n\u003cp\u003eKB \u0026ndash; kissing balloon\u003c/p\u003e\n\u003cp\u003eMACE - major adverse cardiac events\u003c/p\u003e\n\u003cp\u003ePCI \u0026ndash; percutaneous coronary intervention\u003c/p\u003e\n\u003cp\u003eTLF \u0026ndash; target lesion failure\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Data availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe information and data of the study population were extracted from the Hospital Information System. The datasets are not publicly available because the individual privacy of the patients should be protected. However, the data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor Contributions statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm contribution to the paper as follows: study conception and design: M.B., P.R, A.W., M.L, A.D.; data collection: Sz.W., P.W, M.B., P.R., Ł.F., A.J., M.P. analysis and interpretation of results: M.B., K.G., P.R., A.D., M.L.; draft manuscript preparation: M.B. Sz.W, P.R, M.L, A.J., M.P. All authors reviewed the results and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSteigen, TK. \u003cem\u003eet al\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. \u003cem\u003eCirculation\u003c/em\u003e. 114,1955-1961 (2006).\u003c/li\u003e\n\u003cli\u003eElwany, M., Palma GD., Cortese B. Treatment of coronary bifurcation lesions: current knowledge and future perspectives. \u003cem\u003eFuture Cardiol\u003c/em\u003e. 14, 165-179 (2018).\u003c/li\u003e\n\u003cli\u003eAlbiero, R. et al. Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club. \u003cem\u003eEuroIntervention\u003c/em\u003e. 18, e362-e376 (2022).\u003c/li\u003e\n\u003cli\u003eLassen, JF. et al. Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus document of the European Bifurcation Club. \u003cem\u003eEuroIntervention\u003c/em\u003e. 18, 457-470 (2022).\u003c/li\u003e\n\u003cli\u003eDi Gioia, G. et al. Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients. \u003cem\u003eJACC Cardiovasc Interv\u003c/em\u003e. 13, 1432-1444 (2020).\u003c/li\u003e\n\u003cli\u003eBujak, K. et al. Clinical outcomes following different stenting techniques for coronary bifurcation lesions: a systematic review and network meta-analysis of randomised controlled trials. \u003cem\u003eEuroIntervention\u003c/em\u003e. 19, 664-675 (2023).\u003c/li\u003e\n\u003cli\u003eChevalier, B., Glatt, B., Royer, T., Guyon, P. Placement of coronary stents in bifurcation lesions by the \u0026quot;culotte\u0026quot; technique. \u003cem\u003eAm J Cardiol\u003c/em\u003e. 82, 943-949 (1998)\u003c/li\u003e\n\u003cli\u003eFerenc, M. et al. Culotte stenting vs. TAP stenting for treatment of de-novo coronary bifurcation lesions with the need for side-branch stenting: the Bifurcations Bad Krozingen (BBK) II angiographic trial. \u003cem\u003eEur Heart J\u003c/em\u003e. 37, 3399-3405 (2016).\u003c/li\u003e\n\u003cli\u003eWalsh, SJ. et al. Culotte stenting for coronary bifurcation lesions with 2nd and 3rd generation everolimus-eluting stents: the CELTIC Bifurcation Study. \u003cem\u003eEuroIntervention.\u003c/em\u003e 14, e318-e324 (2018).\u003c/li\u003e\n\u003cli\u003eToth, GG. et al. Double-kissing culotte technique for coronary bifurcation stenting. \u003cem\u003eEuroIntervention\u003c/em\u003e. 16, e724-e733 (2020).\u003c/li\u003e\n\u003cli\u003eBarycki, M. et al. Left main calcified lesion treated with orbital atherectomy and two-stent double-kissing Culotte technique in a very elderly patient with frailty syndrome. \u003cem\u003ePostepy Kardiol Interwencyjnej\u003c/em\u003e. 19, 380-381 (2023).\u003c/li\u003e\n\u003cli\u003eKahraman, S., Çizgici, AY., Ertürk, M. A novel coronary bifurcation stenting technique: Double kissing nano-culotte stenting. \u003cem\u003eAnatol J Cardiol.\u003c/em\u003e 27, 113-116 (2023).\u003c/li\u003e\n\u003cli\u003eLunardi, M. et al. Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations. \u003cem\u003eEuroIntervention\u003c/em\u003e. 19, e807-e831 (2023).\u003c/li\u003e\n\u003cli\u003eThygesen, K. et al. Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction. \u003cem\u003eJ. Am. Coll Cardiol\u003c/em\u003e. 72, 2231\u0026ndash;2264 (2018).\u003c/li\u003e\n\u003cli\u003eNeumann, FJ. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. \u003cem\u003eEuroIntervention\u003c/em\u003e. 14, 1435-1534 (2019).\u003c/li\u003e\n\u003cli\u003eMohamed, MS., Mostafa, MM., Abdelfattah, AA. Prediction of side branch occlusion in bifurcational lesions during percutaneous coronary interventions by preprocedural coronary computed tomography using the CT bifurcation score. \u003cem\u003ePostepy Kardiol Interwencyjnej.\u003c/em\u003e 19, 135-141 (2023).\u003c/li\u003e\n\u003cli\u003eSeo, JB. et al. Predictors for Side Branch Failure During Provisional Strategy of Coronary Intervention for Bifurcation Lesions (from the Korean Bifurcation Registry). \u003cem\u003eAm J Cardiol\u003c/em\u003e. 118, 797-803 (2016).\u003c/li\u003e\n\u003cli\u003eZhang, JJ. et al. Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. \u003cem\u003eEur Heart J\u003c/em\u003e. 41, 2523-2536 (2020).\u003c/li\u003e\n\u003cli\u003eChen, SL. et al. Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents. \u003cem\u003eEur J Clin Invest\u003c/em\u003e. 38:361-371 (2008).\u003c/li\u003e\n\u003cli\u003eArunothayaraj, S. et al. Stepwise provisional versus systematic culotte for stenting of true coronary bifurcation lesions: five-year follow-up of the multicentre randomised EBC TWO Trial. \u003cem\u003eEuroIntervention\u003c/em\u003e. 19, e297\u0026ndash;304 (2023).\u003c/li\u003e\n\u003cli\u003eChen, SL. et al. Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. \u003cem\u003eJ Am Coll Cardiol\u003c/em\u003e. 61, 1482-1488 (2013).\u003c/li\u003e\n\u003cli\u003eChen, SL. et al. Clinical Outcome After DK Crush Versus Culotte Stenting of Distal Left Main Bifurcation Lesions: The 3-Year Follow-Up Results of the DKCRUSH-III Study. \u003cem\u003eJACC Cardiovasc Interv\u003c/em\u003e. 8, 1335-1342 (2015).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"acute coronary syndrome, percutaneous coronary intervention, endovascular procedures","lastPublishedDoi":"10.21203/rs.3.rs-4338717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4338717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe double-kissing (DK) culotte technique, a modification of the traditional culotte stenting with additional kissing balloon inflation after first stent implantation, was compared to the conventional culotte technique in a multicenter, observational, retrospective study of 239 patients with acute coronary syndrome. Patients were treated at two high-volume centers, with 117 patients undergoing the DK culotte and 122 patients undergoing the traditional culotte technique. The primary endpoint, target lesion failure (TLF), occurred in 6.84% of the DK culotte group and 13.11% of the culotte group after a one-year period (p\u0026thinsp;=\u0026thinsp;0.085). Major adverse cardiac events (MACE) were also lower in the DK culotte group (12.82% vs. 19.67%; p\u0026thinsp;=\u0026thinsp;0.073), but the differences were not statistically significant. No significant differences were found in contrast medium use (220 mL vs. 230 mL; p\u0026thinsp;=\u0026thinsp;0.214) or cumulative radiation dose (1868 mGy vs. 2114.5 mGy; p\u0026thinsp;=\u0026thinsp;0.127). The results indicate a trend towards better clinical outcomes with the DK culotte technique without increased procedural risks. However, these findings need further validation in prospective studies. ClinicalTrials.gov: NCT06284057\u003c/p\u003e \u003cp\u003e \u003c/p\u003e","manuscriptTitle":"Comparative short-term outcomes of double-kissing culotte and culotte techniques in acute coronary syndrome: A Multicenter Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 18:08:11","doi":"10.21203/rs.3.rs-4338717/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc313069-2b3b-4b5c-8c4d-2d693de2a893","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":31593531,"name":"Health sciences/Cardiology/Interventional cardiology"},{"id":31593532,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2024-12-16T19:51:19+00:00","versionOfRecord":{"articleIdentity":"rs-4338717","link":"https://doi.org/10.3390/jcm13237392","journal":{"identity":"journal-of-clinical-medicine","isVorOnly":true,"title":"Journal of Clinical Medicine"},"publishedOn":"2024-12-04 00:00:00","publishedOnDateReadable":"December 4th, 2024"},"versionCreatedAt":"2024-05-09 18:08:11","video":"","vorDoi":"10.3390/jcm13237392","vorDoiUrl":"https://doi.org/10.3390/jcm13237392","workflowStages":[]},"version":"v1","identity":"rs-4338717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4338717","identity":"rs-4338717","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}